The strange and sad tale of Audrey Kishline  founder of Moderation Management who killed a small girl and her father in a drunken car crash  tells us much about American attitudes towards alcohol, and the politics of American alcoholism treatment.

Everything in Moderation
The debate over alcohol: Is one too many?

Stanton Peele

Audrey Kishline pled guilty June 29 to two counts of vehicular homicide after she killed a 12-year-old girl and the girl's father while driving drunk. For some, this event sounded the death knell for Moderation Management, a support group Kishline founded in 1994 for those who wish to moderate their drinking. Groups like the National Council on Alcohol and Drug Dependence said Kishline's story was a dire lesson for anyone who claimed any problem drinkers can moderate their drinking.

I am such a person: I wrote the introduction to Kishline's 1994 book, "Moderate Drinking." Kishline had contacted me and several other experts in 1993 because she had taken an alternative route after she had been in standard treatment for alcoholism several times. In the United States, these programs are invariably based on the 12 steps of Alcoholics Anonymous and require absolute abstinence. But they hadn't worked for Kishline. And from 1993 through 1999, she seemed to have moderated her drinking successfully.

In fact, the 12 steps and abstinence didn't work for Kishline in 2000, either. In January, two months before she caused the deaths of two innocent individuals, Kishline had announced on MM's Internet discussion group that she was leaving MM to attend AA. And, according to a report by the Seattle Times based on a statement Kishline gave at her plea hearing, "it wasn't long before she was consuming so much wine at night she would drink herself to sleep." Kishline had been attending AA regularly while drinking nightly.

Of course, AA can no more be blamed for Kishline's drunken episode than can MM. It is difficult to judge either group based on the careers of individuals. Many AA members have killed people while driving drunk  I testified at a federal murder trial of an active AA member who got drunk and crossed a medial strip, killing a woman driving in an oncoming car. Consider that Darryl Strawberry, who had devoted himself to AA, Narcotics Anonymous and abstinence (as well as becoming a born-again Christian), was scheduled to deliver a keynote address for the NCADD when he was arrested soliciting a prostitute, with cocaine in his possession, and subsequently failed a Yankees drug test.

In other words, there is more than enough failure to go around.

Research does not indicate that people who quit drinking altogether succeed better than those who do not. The National Institute on Alcohol Abuse and Alcoholism conducted the largest clinical trial of alcoholism treatment in history, called Project MATCH.

In 1997 MATCH published its results. All of the several treatments tried worked well, according to NIAAA Director Enoch Gordis. But not many of the 1,726 subjects stopped drinking altogether  instead, on average, they reduced their drinking from 25 to six days a month and from 15 drinks to three drinks each time they drank.

In the United States, we hold out the hope that all alcoholics will stop drinking entirely. So far, this has not occurred. But, as with sex education aimed at having all children remain virgins, we are committed to the ideal. Many feel it's important that AA and treatment programs tell people not to drink  if they relapse it is because they failed to do what they were told.

But while this has been the dominant approach to alcoholism, Americans are not doing any better with their drinking. Between 1968 and 1984, the number of Americans reporting alcohol-dependence symptoms doubled, and that number has remained high throughout the '90s. Yet we have a more extensive treatment system than any other country in the world. Shouldn't we expect that, with so much treatment, if our approaches were effective, we would see a downturn in the problem being addressed?

Instead of more moderate drinking, we have seen a sharp upturn in the extremes of excessive drinking and total abstinence in the U.S. Since the early 1990s, Henry Wechsler of the Harvard School of Public Health has investigated collegiate binge drinking. Upwards of 40 percent of college students drink heavily at least occasionally. And, despite a series of programs begun on campuses around the country, the percentage who binge frequently increased through the '90s  along with those who abstained.

Courts and employee assistance programs regularly compel people to enter AA. But very few really stick to and succeed with it. Even those who continue to attend for some time will at some point take a drink, at which point they often abandon all restraint. In AA, a slip is the same as a drunken binge  one does not proudly return to the group and announce he or she had a drink but didn't get drunk! Thus, in AA and treatment programs based on it, people usually drink all-out once they begin to drink.

Moderation approaches strive to break this cycle. MM  which is restricted to those with lesser drinking problems (often termed "problem drinkers" rather than "alcoholics")  aims for women to have no more than nine drinks weekly and, for men, 14. For many, MM's guidelines and techniques are helpful.

People sometimes foresee a stressful situation or troubling occurrence that will endanger their sobriety, and they may take steps to remain problem-free. For these and other reasons, they could for a short time, or semi-permanently, replace a moderation goal with abstinence. MM does not lock people into moderating their drinking forever, and in some cases it can be another path to abstinence.

There are many people willing to decree abstinence for others. But only the individual drinker actually can decide if and when he or she will drink.

MM is clearly not for everybody. Many people  especially those heavily dependent on alcohol  do best with abstinence and/or AA. But some of those who wish to abstain may be uncomfortable with the "powerlessness" or "higher power" concepts central to AA. For these people, there are other abstinence-oriented support groups, such as SMART Recovery.

The question is, who will decide which approach is best for them? There are many people willing to decree abstinence for others. But, for better or worse, only the individual drinker actually can decide if and when he or she will drink.

Some people want to drink, and claim they are trying to moderate while they simply continue their alcoholism. But we already know that most people won't quit their alcoholic drinking no matter what. Project MATCH involved the best alcoholism treatment researchers in the U.S. in developing the most sophisticated treatment protocols ever  yet even in this ideal, colossally expensive program, most alcoholics did not abstain after treatment.

Let us take one last look at the Kishline situation. Since she had given up on moderation and was failing at abstinence, what could have been done? Apparently, Audrey (to whom I had not spoken in five years) had no one nearby to whom she could confess that she was actively drinking. It was simply too embarrassing and scary. But if there had been a way for Audrey to deal with this reality  for example, by enlisting family or friends to make sure she did not drive while she tried to resolve her drinking crisis, two human beings might still be alive.

There is no treatment for people in active alcoholic crisis in the U.S. No one would treat Audrey if she admitted to getting drunk nightly  whether they were instructing her to quit or to reduce her drinking. Yet there are more active alcoholics than ever before. If you cannot abstain, presumably forever, you are on your own. This doesn't prevent many people from drinking alcoholically, and worse, from harming themselves and others while doing so. But at least we can proudly state, "We told them not to drink!"